- Abdominal Pain in Children accounts for 9-10% of emergency department and primary care visits
-
Incidence of acute surgical presentations of Abdominal Pain
- Emergency Department: 10-30% of acute Abdominal Pain in Children requires surgery
- Overall: 2% requires surgery
-
Acute Abdominal Pain
- Characteristics
- Less than 4-6 weeks (subacute less than 12 weeks)
- Single episode, self limited and treatable
- Episodic localized pain, sharp, stabbing
- Common Benign Causes (see below for more serious causes)
- Upper Respiratory Infection, Pharyngitis, Otitis Media or sinsuitis (23%)
- Gastroenteritis (15%)
- Constipation (9%)
- Urinary Tract Infection (8%)
- Characteristics
- Chronic Abdominal Pain
- Characteristics
- Three episodes over 3 months
- Continuous, dull, vague and diffuse Abdominal Pain
- Recurrent, Associated with debilitation
- Common Benign Causes (see below for more serious causes)
- Constipation
- Lactose intollerance
- Mittelschmerz
- Psychogenic (See Recurrent Abdominal Pain Syndrome)
- Secondary Gain
- Sexual abuse
- School Phobia
- Characteristics
- See Pediatric Abdominal Pain Causes
- See Differential Diagnosis below
- Red Flags
- Acute
- Bilious Vomiting
- Fever
- Especially if onset after the Abdominal Pain onset (higher risk of peritonitis)
- Localized pain away from midline
- Bloody Diarrhea
- Chronic
- Altered bowel habits
- Growth disturbance
- Nocturnal episodes
- Radiation of pain
- Incontinence urine or stool
- Systemic symptoms
- See Abdominal Pain Evaluation
- Timing
- Onset of Abdominal Pain
- Frequency, Duration and time of day
- Which days of the week
- Characteristics
- Location and radiation of Abdominal Pain
- Intensity and character
- Key Associated Symptoms
- Fever
- Anorexia
- Decreased Activity
- Change in stool consistency or frequency (Diarrhea or Constipation)
- Vomiting
- Vomiting (before or after pain?)
- Bilious Vomiting suggests obstruction
- Bloody stool?
- Peptic Ulcer
- Bowel ischemia
- Genitourinary Symptoms
- Dysuria, urgency, frequency or hematura
- Gynecologic symptoms (e.g. Vaginal Discharge, Vaginal Bleeding)
- Testicular or Scrotal Pain
- Inguinal Masses or Hernias
- Exacerbating and relieving features
- Relationship to activity and school
- Attempted therapies
- Relieved with movement (esp. poorly localized pain)
- Visceral pain (e.g. Volvulus)
- Worse with movement (esp. sharp and localized)
- Hydration status
- Level of alertness (lethargy vs alert and attentive)
- Tolerating oral intake without Emesis? How much intake?
- Adequate Urine Output (>3/day under age 1, and >2/day over age 1)
- Food associations
- Milk or cheese
- Spicy food
- Caffeinated soda, tea
- Other associated symptoms
- Fatigue
- Syncope
- Headache or CNS symptoms
- Upper Respiratory Infection, cough or Pharyngitis
- Consider Streptococcal Pharyngitis
- Consider Pneumonia
- Past Medical History
-
General history
- Surgical history (esp. abdominal surgeries)
- Medications
- Major illnesses or hospitalizations
- Growth and development
-
Sickle Cell Disease
- Splenic Sequestration
- Vaso-Occlusive Pain Crisis
- Gall Bladder disorder
- Intrahepatic cholestasis
-
Immunosuppression
- Immunosuppressed patients with subtle findings despite severe underling abdominal abnormalities
- Neutropenia
-
Anorexia or other condition causing rapid weight loss
- Superior Mesenteric Artery Syndrome may present with severe Abdominal Pain with Vomiting
-
Cerebral Palsy
- Constipation (most common)
- Sigmoid Volvulus
- Ethnic Background
- Migraine Headache
- Seizure Disorder
- Gastroesophageal Reflux disease (GERD)
- Peptic Ulcer Disease (PUD)
- Inflammatory Bowel Disease (IBD)
- Irritable Bowel Syndrome (IBS)
- Pancreatitis
- Hepatitis
- Social History (chronic Abdominal Pain in teens)
- See HEEADSSS Mnemonic (Adolescent History)
- Home
- Death, divorce, serious illness, care providers, siblings
- Education
- Activities
- Drug Use
- Suicidal Ideation
- Sexual activity
- Perform in comfortable, non-threatening environment
- Appearance
- See Inconsolable Crying in Infants
- Moaning in discomfort
- Motionless or lethargy (peritonitis)
- Writhing (e.g. Renal Colic)
-
Vital Signs
- Fever
- Tachycardia
- Weight (compare with prior)
- Comprehensive exam
- Heart, lung and general exam should be performed before abdominal exam
- Evaluate for referred pain
- Throat exam
- Lung Exam
- Hip Exam
- Toxic Synovitis
- Septic hip
- Abdominal exam
- See Abdominal Pain Exam
- Palpation
- Consider asking parents to push on Abdomen (with examiners hands on top)
- Use stethoscope to apply pressure
- Examine the most painful area last (as with all patients)
- Rebound Abdominal Pain
- Avoid removing hand rapidly (loses patient trust)
- May test rebound as "Jump on and off table" or bump the side of the table
- Other red flag findings
- See Abdominal Pain Exam for specific signs (e.g. rosving sign, Psoas Sign)
- Abdominal Distention
- Absent or decreased bowel sounds
- Other peritonitis signs (e.g. abdominal rigidity)
- Genitourinary exam
- Perform in all cases of Pediatric Abdominal Pain
- However, in suspected sexual abuse, exam should be deferred to trained examiner (e.g. forensic nurse)
- Girls
- Ovarian Torsion
- Ectopic Pregnancy (adolescent)
- Pelvic Inflammatory Disease (adolescent)
- Boys
- Perform in all cases of Pediatric Abdominal Pain
-
Rectal Exam
- Consider
- Screening
- Complete Blood Count
- Comprehensive Metabolic Panel (including Liver Function Tests)
- Serum Lipase
- C-Reactive Protein (or ESR)
- Urinalysis
- Clean catch urine or catheterized urine
- Post-pubertal girls
- Urine Pregnancy Test (Urine HCG)
- Consider Gonorrhea PCR and Chlamydia PCR
- Consider additional testing
- Streptococcal Rapid Antigen Test
- Epigastric Pain often accompanies Streptococcal Pharyngitis in children
- Monospot
- Mononucleosis may also present with Abdominal Pain
- Stool Stool NAT or cultures (bloody Diarrhea or Dysentery)
- Parasite evaluation (Chronic Diarrhea)
- Ova and Parasites (Stool NAT often includes Giardia, Cryptosporidium and other Parasites)
- GiardiaAntigen
- Cryptosporidium (Immunocompromised Children)
- Helicobacter Pylori titer (Peptic Ulcer Disease)
- Transaminase increase
- Hepatitis Serologies (Hepatitis A, and if risks, Hepatitis B and Hepatitis C)
- Lead Level
- Streptococcal Rapid Antigen Test
- Flat and Upright abdominal XRay or KUB (not routinely used)
- Typically low yield, but low radiation exposure
- Ingested Foreign Body
- Small Bowel Obstruction
- Abdominal free air
- Constipation (non-specific)
- Appendicolith may be seen in Appendicitis (low yield)
-
Abdominal Ultrasound
- Preferred first-line study for Pediatric Abdominal Pain imaging
- Appendicitis or intussception
- Cholecystitis
- Hydronephrosis or Renal Mass
- Testicular Torsion
- Ovarian Torsion, Ectopic Pregnancy or Tuboovarian Abscess
- Pyloric Stenosis (Projectile Vomiting in young infants)
- Upper GI with Small Bowel follow through
- Evaluate for Volvulus
- Other studies
- Abdominal CT (avoid if possible due to significant radiation exposure)
- Ultrafast 3T MRI (3 Tesla MRI)
- Focused MRI can complete Appendicitis imaging in 6 minutes
- Johnson (2012) AJR Am J Roentgenol 198( 6): 1424-30 [PubMed]
- Skeletal Survey (assess physical abuse)
- Upper endoscopy (EGD)
- Colonoscopy
- Acute Pain
- See Pediatric Abdominal Pain Causes
-
Intussusception
- Most common cause of acute Intestinal Obstruction in ages 3-12 months old
- Ultrasound is preferred imaging modality (high Test Sensitivity and Specificity)
-
Volvulus
- Presents with Bilious Emesis and Abdominal Pain in newborns, infants and young children
- Congenital malrotation of the bowel allows for Volvulus
- Upper GI series is preferred imaging modality
-
Appendicitis
- Classic signs and symptoms of Appendicitis warrant surgical evaluation without imaging
- Ultrasound is typically performed as first-line study in unclear cases
- Surgical Consultation and serial examinations should be considered when Ultrasound is non-diagnostic
- Also consider Meckel Diverticulum
- Urinary Tract Infection
- Gynecologic causes
- Males
- Abdominal mass
- Trauma
- Non-abdominal causes
- Streptococcal Pharyngitis
- Pneumonia
- Abdominal Migraine
- Diabetic Ketoacidosis (common Type 1 Diabetes new presentation)
- Biliary Tract (growing importance due to Childhood Obesity)
- See Acute Abdominal Pain
- See Acute Pelvic Pain
- See Functional Abdominal Pain in Children (Recurrent Abdominal Pain Syndrome)
- Initiate fluid Resuscitation early
- Do not delay Analgesics in Acute Abdominal Pain
- Use Opioid Analgesics where appropriate (as you would for adult patients with Abdominal Pain)
- Obtain early surgical Consultation when acute red flag findings are present
- Bilious Vomiting
- Bloody Diarrhea
- Fever
- Concerning abdominal exam findings (absent bowel sounds, Rebound Tenderness, rigidity or guarding)
-
Constipation is a diagnosis of exclusion
- Consider all serious Abdominal Pain causes first (and exclude based on a careful history and exam)
- Normal labs (including CBC, CRP) do not exclude Appendicitis or intussception
- Serial re-examination in 12-16 hours in uncertain cases
- Diagnosis changes in 30% of cases
- Toorenvliet (2010) World J Surg 34(3):480-6 [PubMed]
- Park (2015) Crit Dec Emerg Med 29(8): 2-8
- Herbert (2012) EM:Rap-C3 2(3):1
- Buel (2024) Am Fam Physician 110(6): 621-31 [PubMed]
- Hijaz (2017) Pediatr Health Med Ther 8:83-91 +PMID: 29388612 [PubMed]
- Leung (2003) Am Fam Physician 67(11):2321-6 [PubMed]
- Reust (2016) Am Fam Physician 93(10): 830-6 [PubMed]